Retained Tissue Postpartum Haemorrhage

Retained tissue postpartum haemorrhage is bleeding after birth because part or all of the placenta, or membranes, remains in the uterus and prevents it from contracting. It causes about 10 percent of postpartum haemorrhage and is the most common cause of secondary bleeding. It matters because retained tissue also causes infection, and it is easily corrected once found.

• Risk factors: preterm birth, previous retained placenta, accessory (succenturiate) lobe, previous curettage or caesarean section, placenta accreta spectrum, mismanaged third stage with cord traction.
• Placenta not delivered within 30 minutes of birth is retained.
• Incomplete placenta or membranes on inspection signals retained tissue.

Women have continued bleeding after birth with a soft, poorly contracted uterus, and the placenta or membranes may be incomplete. Later, bleeding returns with offensive lochia and fever.

• Uterus feels soft and larger than expected.
• Ragged edge of the placenta or missing cotyledon on inspection.
• Differential diagnosis: uterine atony, genital tract tear, uterine inversion, coagulopathy, placenta accreta spectrum, endometritis.
• Complications: postpartum haemorrhage, shock, endometritis, sepsis, subinvolution, Asherman syndrome after curettage, hysterectomy.

The approach is inspection of the delivered placenta and ultrasound of the uterus.

• Inspect placenta and membranes for missing cotyledons, a torn vessel running to the edge (accessory lobe) and intact membranes.
• Palpate the uterus; ultrasound: echogenic tissue in the cavity with endometrial thickness above 15 mm, with colour flow.
• Haemoglobin, platelets, clotting screen, group and cross-match 2 to 4 units.
• Temperature and C-reactive protein if infection is suspected.

The principle is to remove the tissue promptly under antibiotic cover and to give uterotonics to contract the uterus.

• Supportive: two cannulae; Ringer's lactate 1 to 2 litres; empty the bladder; massage the uterus; transfuse for shock; anaesthesia (spinal or general) for removal.
• Pharmacological: oxytocin 10 IU IM then infusion of 20 IU in 1 litre Ringer's lactate at 125 mL per hour for 4 hours; misoprostol 800 micrograms sublingual once; ergometrine 0.2 mg IM (not in hypertension); cefazolin 2 g IV plus metronidazole 500 mg IV before manual removal, then amoxicillin-clavulanate 625 mg oral 8-hourly for 5 days; tranexamic acid 1 g IV over 10 minutes; ferrous sulphate 200 mg oral 8-hourly for 3 months.
• Procedures: manual removal of the placenta or fragments under anaesthesia; evacuation with a blunt curette or suction cannula under ultrasound guidance; hysteroscopic removal of small persisting fragments; balloon tamponade for oozing; laparotomy or hysterectomy if accreta is found and bleeding is uncontrolled.
• Special groups: suspected placenta accreta spectrum (no plane between placenta and uterus) is managed by leaving the placenta in place and referral or by hysterectomy, rather than forceful removal.
• Red flags: heavy bleeding, fever above 38 degrees Celsius, foul lochia, no plane of separation, shock.
• Follow-up: bleeding and temperature observation for 24 hours; ultrasound at 1 week if bleeding persists; haemoglobin at 24 hours; review at 6 weeks.